Observational and randomized controlled studies have shown that periconceptional folic acid (FA) supplementation can significantly reduce the risk of neural tube defects (NTDs). Countries across the world have adopted various strategies to increase awareness and to promote the use of FA. Nevertheless, health promotion and educational campaigns have proven to be ineffective in achieving the goal of increasing FA intake by the at-risk group. Mandatory FA fortification was a further step taken by some countries on the course toward improving folate status in the general population. Although some researchers advocate for extra folate to be added to the food supply, a number of governments have refrained from adopting the policy of mandatory fortification because of concerns raised over the potential side effects, such as cancer risk; however, epidemiological confirmation is inconsistent. After several years of the proven association between prenatal supplementation of FA and prevention of NTD, uncertainty, controversy, and indecision still hinder FA promotion and use. In this review, we summarize approaches taken by various countries and provide a framework for further steps in this area.
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